Most important changes in the policy terms in 2015

Most important changes in the policy terms in 2015
Changes in the basic insurance
Everyone who lives or works in the Netherlands must have health insurance. The basic insurance covers standard care
e.g. from a general practitioner, a hospital or a pharmacy. The government determines the contents of the basic insurance.
The contents of the basic insurance will change in 2015. We have drawn up a list of the changes for you.
Basis Budget
In 2015 the mandatory excess will be €375.00 instead of the €360.00 from 2014.
The mandatory and voluntarily chosen excess doest not apply to nursing and care in your own environment and to the travel costs of a
donor if these are reimbursed under the donor's own basic insurance.
In order to keep health care affordable, a remuneration ceiling will be agreed with care providers with whom we enter into a contract.
Once a remuneration ceiling has been reached, we can remove care providers (temporarily) from the list of contracted care providers
(Medical Provider Search Tool). This means that the contracted care providers as of 1 January 2015 will not necessarily be the same
contracted care providers as of (for instance) 1 December 2015.
Extended: if you visit a non-contracted care provider for paramedical care, transport and mental health care (GGZ), then we will reimburse at
the most, 75% of the average contracted fee. This reimbursement is higher than in 2014.
Limited contracts for medical devices lapses. From now on you can obtain all your medical devises from any of the contracted suppliers.
Do you want to know with which care providers and healthcare institutions we have a contract in 2015 (specially for the Basis Budget)?
Use the Medical Provider Search Tool on zk.nl/zorgzoeker.
The period for dealing with a complaint or a re-assessment is now 20 working days (was 3 weeks).
New: in principle, non-registered allergens are not eligible for reimbursement, unless treatment with a registered drug is not possible.
In that case, the prescribing doctor can apply for an authorisation for the reimbursement of a non-registered allergen.
The definition of ‘medical necessity’ in relation to the prescription of drugs has been amended in the Pharmaceutical Care Regulations,
in order to provide greater clarity regarding the applicable terms.
The Medicines holiday form relating to spending a longer period of time abroad has lapsed. Your pharmacist can make agreements with us if
you need medicines for a longer period.
If a frozen embryo is replaced after an ongoing pregnancy, the replacement of the frozen embryo is treated as a first attempt and no longer
as part of the attempt from which it was created.
A number of alterations have been made in the Medical Devices Regulations which is an integral part of the entitlement to medical devices.
See zk.nl/zorgin2015 for detailed regulations.
As of 1 January, care for severe dyslexia will no longer be reimbursed under your basic insurance, but under the Youth Act (Jeugdwet).
As of 1 January, GGZ care for children up to 18 years will no longer be reimbursed under your basic insurance, but under the Youth Act.
It remains a part of the basic insurance for insured clients aged 18 years or older.
As of 2015, the costs of the first 3 years of treatment-oriented admission in a case of long-term mental health care (GGZ) are covered by
your basic insurance. This used to be only the first year.
We reimburse an annual examination within the framework of footcare for insured clients with diabetes mellitus, if a care profile has been
drawn up. During the annual examination, the GP or specialist establishes whether you are at risk of developing foot complaints due to diabetes.
Only if this is the case will a care profile be drawn up. Whether a pedicure treatment is reimbursed under the basic insurance depends on your
care profile.
You need prior authorisation from us for a dental operation for the treatment of obstructive Sleep Apnoe Syndrome (OSAS).
The care of insured clients with an auditive handicap, a visual handicap and/or the care of insured clients up to 23 years with a
communicative handicap as a consequence of a primary language development disorder is now covered by the basic insurance.
For all reimbursements, see your policy terms on zk.nl/voorwaarden.
Access to geriatric rehabilitation care has been broadened. Such care must take place within 1 week after your hospital stay or after an acute
disorder involving an acute mobility disorder.
The reimbursement for district nursing care has been transferred from the Exceptional Medical Expenses Act (AWBZ) to the basic insurance.
The reimbursement for prenatal care has been expanded to include the NIPT (Non-Invasive Prenatal Test). The combination test will only be
reimbursed if you were referred by a general practitioner, an obstetrician, midwife or a medical specialist.
Extension: we now also reimburse the costs of repairing a set of full removable dentures if it is carried out by a dental technician.
A lot has changed in the Exceptional Medical Expenses Act (AWBZ). The changes are explained in the brochure.
In 2015, the costs of the online self-help course Kleur je Leven will be covered by the mandatory and/or voluntarily chosen excess.
Each year the government indexes the statutory personal contributions and the statutory maximum reimbursements. A summary of the
statutory personal contributions and the statutory maximum reimbursements can be found on zk.nl/zorgin2015.
New: your sports doctor is now able to refer you to a medical specialist.
Changes in the supplementary insurance policies
In addition to the basic insurance, you can opt for a supplementary insurance. This will provide you with greater cover, because
not all care costs are covered by the basic insurance. Such as the costs of orthodontics, physiotherapy or spectacles and lenses.
The contents of supplementary insurance will also change. Some reimbursements have lapsed and some reimbursements
have been extended. We have drawn up a list of the changes in the supplementary insurance policies for you.
General
Zilveren Kruis Achmea is entitled to change a product or take it off the market. In that case, we must offer a suitable alternative. This applies
to all our products.
In 2015 the premium will be deducted on or around the 27th of the month instead of on or around the 1st of the month.
Supplementary 1 star
Accident coverage for dental care has changed. Full details on reimbursement for dental care after an accident can be found on zk.nl/
vergoedingen.
New: we reimburse the costs of replacing front teeth for insured clients aged 18 to 24 years if damage occurred before they were 18 years.
The €240.00 reimbursement for alternative forms of treatment, therapies and medicines has lapsed.
New: we reimburse the costs of the statutory personal contribution for contraceptives if they are supplied by a contracted care provider.
Extended: instead of 6 sessions, we reimburse 9 sessions of physiotherapy and/or remedial therapy.
The reimbursement of exercise programmes for obesity, past heart failure, diabetes type 2, COPD or rheumatoid arthritis lapses.
New: we reimburse the costs of a physiotherapeutic after-care path by a Pluspraktijk contracted for this purpose in cases involving oncology,
heart and vascular diseases and after a stroke.
New: we reimburse a maximum of €750.00 of the statutory personal contribution on medicines from the basic insurance. ADHD medicines
are not covered by this reimbursement.
New: for a number of disorders we reimburse a maximum of €750.00 for registered medicines and pharmacy preparations that are not
reimbursed under the basic insurance.
New: we reimburse a maximum of €1,200.00 for the convalescence programme Herstel en Balans for the duration of the insurance.
New: we reimburse a maximum of €1,000.00 for assistance at home for insured clients aged 18 years and older in a case of loss of ADL
(activities of daily living) following a stay in hospital.
The reimbursement for child care at home for children up to 12 years during or after hospitalisation of parent(s) has lapsed.
The reimbursement of the subscription costs for the use of a personal alert system has lapsed.
Supplementary 2 star
New: we reimburse once, for the duration of the insurance, the subscription costs for the self-help programme Slimmer Zwanger
(A smarter way of getting pregnant).
The accident cover for dental care has changed. Exclusions have been included. Full details on reimbursement for dental care after an accident
can be found on zk.nl/vergoedingen
New: we reimburse the costs of replacing front teeth for insured clients aged 18 to 24 years years if damage occurred before they were
18 years.
Extended: the reimbursement for alternative forms of treatment, therapies and medicines will be €40.00 per day up to a maximum of
€450.00. This used to be a maximum of €440.00. Changes have been made in the overview of alternative healers and therapists that we
reimburse. This overview can be found on zk.nl/zorgin2015.
New: we reimburse the costs of the statutory personal contribution for contraceptives if they are supplied by a contracted care provider.
New: we reimburse the costs of a physiotherapeutic after-care path by a Pluspraktijk contracted for this purpose in a case of oncology,
heart and vascular diseases and after a stroke.
New: we reimburse a maximum of €750.00 of the statutory personal contribution on medicines from the basic insurance. ADHD medicines
are not covered by this reimbursement.
New: for a number of disorders we reimburse a maximum of €750.00 for registered medicines and pharmacy preparations that are not
reimbursed under the basic insurance.
Extended: the reimbursement for the convalescence programme Herstel en Balans will be €1,200.00 instead of €800.00 for the duration
of the insurance.
New: we reimburse a maximum of €1,000.00 for assistance at home for insured clients aged 18 years and older in a case of loss of ADL
(activities of daily living) following a stay in hospital.
New: we reimburse the costs of an artificial nipple or a mamilla prosthesis.
The reimbursement of €1,500.00 for orthodontics for children up to 18 years has lapsed. The reimbursement is extended in the 3 and 4 star
supplementary insurance.
New: we reimburse a maximum of €250.00 for male circumcisionfor religious reasons.
Extended: we reimburse the statutory €4.15 per hour personal contribution for maternity care at home or in a birth centre or a maternity
centrein full instead of for a maximum of 24 hours.
Supplementary 3 star
New: we reimburse once, for the duration of the insurance, the subscription costs for the self-help programme Slimmer Zwanger (A smarter
way of getting pregnant).
The accident cover for dental care has changed. Exclusions have been included. Full details on reimbursement for dental care after an
accident can be found on zk.nl/vergoedingen .
New: we reimburse the costs of replacing front teeth for insured clients aged 18 to 24 years if damage occurred before they were 18 years.
The reimbursement for alternative forms of treatment, therapies and medicines will be €40.00 per day up to a maximum of €650.00. This
used to be a maximum of €640.00. Changes have been made in the overview of alternative healers and therapists that we reimburse. This
overview can be found on zk.nl/zorgin2015.
New: we reimburse the costs of the statutory personal contribution for contraceptives if they are supplied by a contracted care provider.
New: we reimburse a maximum of €750.00 of the statutory personal contribution on medicines from the basic insurance. ADHD medicines
are not covered by this reimbursement.
New: we reimburse the costs of a physiotherapeutic after-care path by a Pluspraktijk contracted for this purpose in a case of oncology, heart
and vascular diseases and after a stroke.
New: for a number of disorders we reimburse a maximum of €750.00 for registered medicines and pharmacy preparations that are not
reimbursed under the basic insurance.
Extended: the reimbursement for the convalescence programme Herstel en Balans will be €1,200.00 instead of €1,000.00 for the duration
of the insurance.
New: we reimburse the costs of an artificial nipple or mamilla prosthesis.
Extended: instead of 90% of the costs, we reimburse 100% of the costs of orthodontics for insured clients up to 18 years, up to a maximum
of €2,000.00, for the duration of the insurance.
For pedicure care in a case of rheumatic arthritis or diabetes we reimburse €25.00 per treatment instead of €23.00, up to a maximum of
€100.00. For all reimbursements, see zk.nl/zorgin2015.
New: we reimburse a maximum of €100.00 per day up to a maximum of €2,800.00 per person per calendar year, of the costs of a
convalescent home and/or care hotel.
Extended: we reimburse the statutory €4.15 per hour personal contribution for maternity care at home or in a birth centre or a maternity
centre in full, instead of for a maximum of 24 hours.
Supplementary 4 star
New: we reimburse once, for the duration of the insurance, the subscription costs for the self-help programme Slimmer Zwanger (A smarter
way of getting pregnant).
Changes have been made in the list of non-registered medicines that we reimburse. The list can be found on zk.nl/vergoedingen, under
medicines. The €800.00 reimbursement will be reduced to €750.00.
Accident coverage for dental care has changed. Exclusions have been included. Full details on reimbursement for dental care after an
accident can be found on zk.nl/vergoedingen.
New: we reimburse the costs of replacing front teeth for insured clients aged 18 to 24 years if damage occurred before they were 18 years.
The reimbursement for alternative forms of treatment or therapies and medicines will be €40.00 per day up to a maximum of €850.00. This
used to be a maximum of €840.00. Changes have been made in the overview of alternative healers and therapists that we reimburse. This
overview can be found on zk.nl/zorgin2015.
New: we reimburse the costs of a physiotherapeutic after-care path by a Pluspraktijk contracted for this purpose in a case of oncology, heart
and vascular diseases and after a stroke.
New: we reimburse the costs of the statutory personal contribution for contraceptives if they are supplied by a contracted care provider.
The reimbursement of the statutory personal contribution for medicines from the basic insurance will be reduced from €1,000.00 to
€750.00. This includes ADHD medicines.
New: we reimburse the costs of an artificial nipple or mamilla prosthesis.
Extended: instead of 90% of the costs, we reimburse 100% of the costs of orthodontics for insured clients up to 18 years, up to a maximum
of €2,500.00 for the duration of the insurance.
New: the costs of non-urgent medical care abroad via Royal Doctors will be reimbursed.
New: we reimburse €125.00 per day for all family members together for accommodation expenses abroad and a maximum of €600.00 for
transport costs abroad of family members in a case of admission abroad if it is arranged via Royal Doctors (for own transport the
reimbursement is €0.31 per kilometre).
New: we reimburse a maximum of €600.00 for transport costs abroad in a case of admission abroad if it is arranged via
Royal Doctors (for own transport the reimbursement is €0.31 per kilometre).
For pedicure care in a case of rheumatoid arthritis or diabetes, we reimburse €25.00 per treatment instead of €23.00, up to a maximum of
€150.00. Full details on reimbursement can be found on zk.nl/pedicure.
Extension: we reimburse a maximum of €100.00 per day up to a maximum of €2,800.00 per person per calendar year (was €50.00 per day
up to a maximum of 28 days) of the costs of a convalescent home and/or care hotel.
We reimburse up to a maximum of 40 sessions of physiotherapy and/or remedial therapy instead of all sessions.
Extra Sport
New: running coaching to prevent or deal with injuries: make use of 1 online coaching path via FysioRunning.
New: you can make use of 3 online treatment paths via HelloFysio.
We reimburse 50% of the costs of a sports massage by a sports masseur up to a maximum of €50.00 if the sports masseur is affiliated with
the Dutch Association for Sport Massage (NSG). The discount arrangement has lapsed.
New: we reimburse a maximum of €120.00 per person per calendar year for dietary information provided by a weight consultant affiliated
with the Professional Association of Weight Consultants (Beroepsvereniging Gewichtsconsulenten Nederland, (BGN)) or a (sports) dietician.
Extra Fit
New: running coaching to prevent or deal with injuries: make use of 1 online coaching path via FysioRunning.
New: we reimburse €125.00 for medical fitness, only with a PlusPraktijk we have contracted for this purpose.
New: we reimburse 75% up to a maximum of €115.00 for preventive exercise programmes.
Extended: we reimburse 75% up to a maximum of €115.00 for the preventive courses “Workshop Working Parents Program” by care partner
the Opvoeddesk and a “memory training” by a home care institution.
The discount arrangement for a sports massage from a sports masseur has lapsed.
The €100.00 reimbursement for a sports examination by a Sports Medical Institution has lapsed.
Extra Vitaal
The reimbursement of grief and bereavement support with the Instituut Leefstijl, Training en Coaching (LTC, a personal development and
health management institute) has lapsed. From now on you can approach Interapy. We reimburse 75% of the costs up to
a maximum of €1,250.00 per person per calendar year. New: we reimburse €125.00 for medical fitness, only with a PlusPraktijk we have
contracted for this purpose.
New: you are entitled to 1 consultation per 3 years with an optometrist.
For pedicure care after a cerebrovascular accident we reimburse €25.00 per treatment instead of €23.00, up to a maximum of €100.00.
New: we reimburse the personal training (introduction package) of care providers with whom we have entered into an agreement.
New: we reimburse, for a period of 4 weeks, the costs of using a personal alarm system and the subscription costs of a contracted supplier.
New: we reimburse 75% up to a maximum of €115.00 for preventive exercise programmes.
In 2015 the services that used to be carried out by the zorgregelaar will be carried out by the personal care coach.
New: we reimburse a maximum of €150.00 per person, for the duration of the supplementary insurance, for the costs of the fall prevention
programme, “In Balans”, given by a PlusPraktijk for physiotherapy and/or remedial therapy.
The reimbursement for convalescent homes has lapsed. This reimbursement is currently covered by the 3 and 4 star Supplementary
insurance.
The reimbursement for a hospice has lapsed. In its place a reimbursement has been included in the 3 and 4 star supplementary insurance.
No rights may be derived based on this overview of alterations.
404853-1411
The policy terms and applicable regulations determine the reimbursement to which you are entitled.
These can be downloaded from www.zilverenkruis.nl or requested from our Customer Service Department
(071) 751 00 51.